Greg%Abbott s%healthy%texans%plan!

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1 Women s%health% Greg%Abbott s%healthy%texans%plan Recommendation:"Add"optional"screening"and"treatment"for"postpartum"depression"to"the"types"of" Recommendation:"Increase"funding"for"Texas"women s"health"programs"to"expand"the"types"of" services"covered"for"eligible"women"enrolled"in"the"program. Services%for%Survivors%of%Sexual%Assault%and%Abuse Recommendation:"Increase"appropriations"to"the"Office"of"the"Attorney"General"to"increase"by"100" provide"an"improved"level"of"care"and"compassion"for"victims,"along"with"careful"evidence"collection" and"the"expertise"needed"for"effective"prosecution." Recommendation:"To"provide"more"services"and"greater"protection"for"victims"of"domestic"abuse," create"domestic"violence"high"risk"teams,"which"unite"law"enforcement,"medical"professionals"and" victim"advocates"at"the"local"level"to"review"cases"of"domestic"violence,"and"identify,"monitor,"and" contain"the"most"dangerous"perpetrators"before"they"can"inflict"deadly"harm. Mental%and%Behavioral%Health%Care Recommendation:"Extend"loan"forgiveness"programs"to"mental"health"professionals"who"practice"in" underserved"areas. Recommendation:"Offer"designated"mental"and"behavioral"health"screening"days"for"veterans"and" service"members"near"military"installations. Disability%Services 1"

2 Increasing%Accountability%of%Benefits Recommendation:"Transform"social"service"delivery"and"provide"more"comprehensive"support"by" Recommendation:"Request"federal"Medicaid"funds"in"the"form"of"a"block"grant. State%ConsumerCDirected%Health%Plan% Recommendation:"Allow"eligible"participants"of"the"group"benefits"program"under"the"Texas" Employees"Group"Benefits"Act"to"enroll"in"health"savings"accounts"(HSAs)." Telemedicine Recommendation:"Encourage"pay"parity"for"phone"consultations"by"allowing"a"physician"to"charge"for" a"telephone"consultation"with"a"covered"patient"if"an"employee"benefit"plan"or"health"insurance"policy" allows"any"other"person"to"charge"for"telephone"consultations"with"covered"patients. Supporting%the%Medical%Profession Recommendation:"Increase"the"number"of"residency"positions"available"in"Texas"for"medical"school" graduates. 2"

3 Background%of%Recommendations The"objective"of"Healthy"Texans"is"to"improve"access"to"quality"care"by"making"strategic"improvements" to"the"vast"network"of"doctors,"hospitals,"and"clinics,"both"public"and"private. extensive."health"and"human"services"(hhs)"is"the"second"largest"government"function"after"public"and" totaling"$73.9"billion,"or"36.9"percent"of"all"state"appropriations. 1 "Five"agencies,"including"the"Texas" Health"and"Human"Services"Commission"(HHSC),"form"the"HHS"system. 2 "Spending"on"the"state s" Medicaid"program"constitutes"more"than"three"quarters,"or"$56.2"billion,"of"HHS"appropriations." Along"with"HHSC,"more"than"50"state"agencies"and"higher"education"institutions"spend"more"than"$30" billion"annually"on"direct"healthcare"services,"such"as"medicaid"for"the"poor,"disabled,"and"elderly;" mental"health"services;"medical"benefits"for"state"employees"and"retirees;"and"healthcare"for"prisoners. 3 " The"state"provides"health"insurance"to"4.2"million"Medicaid"recipients"(3.1"million"children)"and"400,000" Children s"health"insurance"program"(chip)"enrollees,"and"cash"grants"to"approximately"100,000" Temporary"Assistance"for"Needy"Families"(TANF)"clients. 4 "Last"session,"the"Texas"Legislature"authorized" $240"million"dollars"for"women s"health an"increase"of"$113"million"over"the"previous"biennium which"is"expected"to"serve"170,000"women,"providing"them"with"cancer"screening,"wellness"exams,"and" other"health"services." All"Funds"appropriations"for"State"Supported"Living"Centers,"which" provide"campus@based"direct" services"and"supports"to"people"with"intellectual"and"developmental"disabilities, 5 "were"approximately" $1.3"billion"in"2014@15,"and"lawmakers"invested"$263.4"million"($312.4"million"All"Funds)"to"expand" mental"health"services."as"of"2010,"the"comptroller s"office"reported"there"were"129"hospital"districts" with"independent"taxing"authority. 6 "Hospital"districts"are"countywide"and"provide"hospital"care"and" medical"aid"to"indigent"individuals"within"the"district. 7 1 " Fiscal"Size"Up"2014@2015"Biennium, "Legislative*Budget*Board,"Feb"2014." 2 "The"remaining"four"include:"Department"of"Aging"and"Disability"Services"(DADS),"Department"of"State"Health"Services"(DSHS)," Department"of"Assistive"and"Rehabilitative"Services"(DARS),"and"Department"of"Family"and"Protective"Services"(DFPS)" 3 " Health"Care"Costs"in"Texas, "Texas*Comptroller*of*Public*Accounts." 4 " Fiscal"Size"Up"2014@2015"Biennium, "Legislative*Budget*Board,"Feb"2014." 5 " About"State"Supported"Living"Centers, "DADS." 6 " Your"Money"and"the"Taxing"Facts, "Texas*Comptroller*of*Public*Accounts,"Aug"2012." 7 "Texas"Health"and"Safety"Code" " 3"

4 Texas"is"also"served"by"a"robust"network"of"Federally"Qualified"Health"Centers"(FQHCs),"organizations" that"receive"grants"under"the"public"health"service"act"and"qualify"for"enhanced"reimbursement"from" Medicare"and"Medicaid. 8 "FQHCs"are"required"to"offer"a"sliding"fee"scale,"provide"comprehensive" services,"and"serve"an"underserved"area"or"population. 9 "Services"are"provided"to"Medicare,"Medicaid," CHIP,"insured,"and"uninsured"individuals"who"may"be"eligible"for"services"based"on"their"family"income" and"on"a"sliding"fee"schedule. 10 "There"are"70"FQHCs"in"Texas"operating"more"than"300"sites. 11 " Over"the"last"six"biennia,"HHS"spending"has"grown"by"68.7"percent. 12 "While"approximately"half"of"the" increase"in"spending"may"be"attributed"to"factors"such"as"population"growth"and"inflation,"after" adjusting"for"these"factors,"all"funds"spending"levels"for"healthcare"increased"by"34.6"percent"and" General"Revenue"Funds"increased"by"33.7"percent,"or"an"average"biennial"increase"of"6"percent. 13 " Looking"ahead"to"the"next"budget"cycle,"the"five"HHS"system"agencies"have"requested"a"total"of"$83.8" billion"all"funds"for"the"2016@17"biennium,"an"increase"of"$8.1"billion"over"the"2014@15"biennium."this" increase,"if"approved,"will"amount"to"an"11"percent"increase"over"the"preceding"biennium,"nearly"twice" the"annual"biennial"increase"experienced"over"the"last"decade." Given"the"extensive"and"expensive"system"of"taxpayer@supported"healthcare"in"Texas,"it"is"essential"that" policymakers"build"on"the"best"network"of"healthcare"services"to"enhance"access"to"quality"care"that" focuses"on"prevention,"early"detection,"and"immediate"treatment"to"improve"health"outcomes"and"hold" down"long@term"costs"as"much"as"possible." 8 " What"are"Federally"Qualified"Health"Centers, "U.S."Department"of"Health"and"Human"Services." 9 "Id." 10 Texas"Primary"Care"Office"@"Federally"Qualified"Health"Centers, "Texas"Department"of"State"Health"Services,"Nov"8,"2013." 11 "Id.*" 12 " Fiscal"Size"Up"2014@2014"Biennium "Texas"Legislative"Budget"Board,"Feb"2014." 13 "Id." 4"

5 Women s%health% Recommendation:"Add"optional"screening"and"treatment"for"postpartum"depression"to"the"types"of" Depression"is"the"leading"cause"of"disability"among"women"in"the"U.S.,"accounting"for"$30"billion"to"$50" billion"in"lost"productivity"and"direct"medical"costs"annually. 14 "Postpartum"depression"refers"to" moderate"to"severe"depression"a"woman"experiences"after"giving"birth. 15 "In"a"CDC"survey,"8"to"19" percent"of"women"reported"having"frequent"postpartum"depressive"symptoms. 16 "When"undetected"or" left"untreated,"symptoms"of"postpartum"depression"can"persist"for"many"months"or"even"years. 17 " While"there"is"no"single"cause"of"postpartum"depression,"physical"changes"after"childbirth,"emotional" factors,"and"lifestyle"changes"can"all"contribute"to"the"onset"of"postpartum"depression. 18 "Women"also" have"a"higher"risk"of"developing"postpartum"depression"if"they: 19 Have"a"history"of"depression; Experienced"postpartum"depression"after"a"previous"pregnancy; Have"experienced"stressful"events"during"the"past"year,"such"as"pregnancy"complications," illness,"or"job"loss; Are"having"problems"in"their"relationship"with"their"spouse"or"significant"other; Have"a"weak"support"system; Have"financial"problems. 14 " Screening"for"Depression"During"and"After"Pregnancy, "The*American*College*of*Obstetricians*and*Gynecologists,"Feb"2010." 15 " Depression"Among"Women"of"Reproductive"Age, "Centers"for"Disease"Control"and"Prevention,"Nov"13,"2013." 16 "Id." 17 depression/ds00546/dsection=symptoms" 18 depression/ds00546/dsection=causes" 19 5"

6 Many"of"the"risk"indicators"listed"above"are"more"prevalent"among"women"at"the"lower"end"of"the" socioeconomic"spectrum,"meaning"women"eligible"for"services"through"the"state s"women s"health" programs"may"be"at"a"higher"risk"of"experiencing"symptoms"of"postpartum"depression. 20 "In"Texas," pregnant"women"may"be"eligible"for"perinatal"coverage"through"chip."women"enrolled"in"chip"perinatal" are"covered"for"two"postpartum"doctor"visits"within"the"first"60"days"of"giving"birth. 21 "CHIP"Perinatal" does"not"cover"mental"health"treatment"for"the"mother " Maximum%Monthly% Income%Limit%for% Medicaid%for%Pregnant% Women 24 Maximum%Monthly% Income%Limit%for%CHIP% Perinatal 25 Family"Size Income"Limit Income"Limit 1 $1,772 $2,014 2 $2,392 $2,714 3 $3,011 $3,416 4 $3,631 $4,115 5 $4,251 $4,815 6 $4,871 $5,517 7 $5,490 $6,216 8 $6,110 $6,916 For"each"additional" person,"add: $620 $ " Sociodemographic"predictors"of"antenatal"and"postpartum"depressive"symptoms"among"women"in"a"medical"group" practice, "Rich@Edwards,"Journal*of*Epidemiology*and*Community*Health,"March"2006." 21 Model"Application"Template"for"State"Child"Health"Plan"Under"Title"XXI"of"the"Social"Security"Act"State"Children s"health" Insurance"Program, "Texas*Health*and*Human*Services*Commission,*March"1,"2012." 22 " CHIP"Perinatal"Benefits, "HHSC." 23 " Texas"Medicaid"and"CHIP"in"Perspective:"Ninth"Edition"@"January"2013,"Chapter"5:"Medicaid"Clients, "HHSC,"Jan"2013." 24 Medicaid"for"low@income"pregnant"women, "HHSC." 25 " CHIP"Perinatal"Benefits, "HHSC.* 6"

7 % (expected) 2015% (expected) Average"Pregnant"Women"Medicaid" Recipient"Months"Per"Month 125, , , ,560 Average"CHIP"Perinatal"Recipient" Months"Per"Month 65,817 69,316 36,895 36,896 Total 191, , , ,456 Symptoms"of"depression"can"manifest"anytime"during"pregnancy"or"within"the"first"year"of"giving"birth. 28 " Infants"of"depressed"mothers"exhibit"delayed"psychological,"cognitive,"neurological,"and"motor" development. 29 "Pregnancy"and"the"postpartum"period"present"unique"opportunities"for"screening," diagnosing,"and"treating"depression"due"to"the"consistent"contact"women"have"with"the"healthcare" delivery"system"during"this"time."diagnosing"and"treating"symptoms"of"postpartum"depression"benefits" both"the"mother"and"her"family;"children s"mental"and"behavioral"disorders"improve"when"maternal" depression"is"in"remission. 30 " If"left"untreated,"symptoms"of"postpartum"depression"may"last"for"months"or"years,"jeopardizing"the" health"and"safety"of"the"mother"and"her"child. 31 "In"2001,"Clear"Lake"mother"Andrea"Yates"drowned"her" five"children"while"suffering"from"a"rare"disorder"called"postpartum"psychosis."in"the"aftermath"of"this" tragedy,"lawmakers"passed"a"bill"requiring"healthcare"providers"who"provide"prenatal"care"to"a"pregnant" woman"to"give"her"a"list"of"resources"that"provide"postpartum"counseling"and"assistance"to"parents. 32 " The"Yates"case,"and"laws"passed"in"its"aftermath,"raised"awareness"of"postpartum"depression,"but"more" needs"to"be"done"to"ensure"new"moms"have"access"to"screening"and"care." "Id." 28 " Depression"During"Pregnancy"&"Postpartum, 29 "" Screening"for"Depression"During"and"After"Pregnancy, "The*American*College*of*Obstetricians*and*Gynecologists,"Feb"2010." 30 "Id." 31 " Postpartum"Depression, "Medline*Plus,*Aug"15,"2014." 32 "House"Bill"341"(78R)" 7"

8 The"state"plans"to"spend"a"portion"of"the"increased"funding"approved"during"the"83 rd "Legislative"Session" for"women s"health"providing"wraparound"benefits,"such"as"prenatal"and"dental"care"for"pregnant" women,"that"are"not"covered"by"other"public"health"programs. 33 "Lawmakers"should"also"consider" expanding"benefits"under"chip"perinatal"and"medicaid"for"pregnant"women"to"cover"screening," diagnosis,"and"treatment"for"postpartum"depression."as"a"starting"point,"the"coverage"period"for" postpartum"doctor"visits"for"the"mother"under"chip"perinatal"should"be"extended"from"60"days"to"up"to" one"year."a"woman"who"reports"having"symptoms"of"postpartum"depression"to"her"postnatal"care" provider"will"be"screened"for"postpartum"depression"and"may"be"referred"to"a"mental"healthcare" provider"that"accepts"medicaid"for"diagnosis"and"treatment." When"properly"treated,"most"women"respond"well"and"show"signs"of"recovery"within"six"to"eight" weeks. 34 instances,"patients"should"be"referred"to"a"fqhc"where"they"can"continue"receiving"treatment"for" depression." Multiple"postpartum"depression"screening"tools"exist,"including"the"Edinburgh"Postnatal"Depression" Scale"and"Postpartum"Depression"Screening"Scale,"and"most"can"be"completed"within"10"minutes. 35 "In" the"event"a"woman"receiving"coverage"through"medicaid"or"chip"perinatal"screens"positive"for"signs"of" postpartum"depression,"she"would"be"eligible"for"mental"health"services"through"medicaid"or"through" one"of"the"state s"public"health"programs."legislation"passed"in"2005"required"hhsc"to"conduct"a"study" on"the"feasibility"of"providing"12"months"of"health"services"under"medicaid"to"women"who"are" diagnosed"with"postpartum"depression"and"who"are"eligible"for"medical"assistance"at"the"time"of"the" diagnosis. 36 "The"study"found"that"the"cost"of"providing"a"benefit"package"limited"to"mental"health" services"for"10"months"following"the"current"60"day"period"would"cost"an"estimated"$426,742"in"general" be"$1.7"million"(all"funds). 37 "Adjusting"for"inflation"and"enrollment"growth,"the"expected"cost"of" implementing"such"a"program"in"2016"would"be"$2"million"initially"and"approximately"$500,000"annually" 33 " New"Abortion"Limits,"but"More"Money"for"Women s"health, "Becca"Aaronson,"The*Texas*Tribune,"Aug"9,"2013." 34 Frequently"Asked"Questions, "State*of*New*Jersey*Department*of*Health,"Jul"12,"2012." 35 "" Screening"for"Depression"During"and"After"Pregnancy, "The*American*College*of*Obstetricians*and*Gynecologists,"Feb"2010." 36 "Senate"Bill"826"(79R)" 37 " Postpartum"Depression"Study, 8"

9 Recommendation:"Increase"funding"for"Texas"women s"health"programs"to"expand"the"types"of" services"covered"for"eligible"women"enrolled"in"the"program. The"state"operates"three"programs"that"provide"preventive"healthcare"to"women:"the"Texas"Women s" Health"Program"(operated"by"HHSC),"Department"of"State"Health"Services"(DSHS)"Family"Planning" authorized"$240"million"to"fund"women s"health 38 a"$113"million"increase"over"the"previous"biennium." Currently"the"Texas"Sunset"Advisory"Commission"is"considering"measures"to"consolidate"and"streamline" the"state s"health"programs"for"women"to"promote"better"access"among"eligible"clients."in"the" meantime,"there"is"still"much"that"can"be"done"to"bolster"the"support"women"receive"from"the"texas" Women s"health"program"(twhp)." The"Texas"Women s"health"program"(twhp)"serves"women"between"ages"18"and"44"who"earn"up"to"185" percent"of"the"federal"poverty"level."since"the"program"focuses"on"family"planning,"women"who"are" already"pregnant"are"not"eligible."covered"services"include"pelvic"examinations,"std"screenings"and" treatment,"hiv"screenings,"diabetes"screenings,"high"blood"pressure"screenings,"cholesterol"screenings," breast"and"cervical"cancer"screenings,"and"contraceptives." 38 "$72.4"million"to"fund"the"Texas"Women s"health"program;"$43.2"million"appropriated"to"dshs"family"planning;"$100"million" to"dshs"expanded"primary"health"care"(epch);"$24.5"million"to"dshs"breast/cervical"cancer"screening." 9"

10 All%Funds%Appropriations%for%Women s%health%services 39 Texas"Women s"health"program $72.3"million 40 $72.4"million DSHS"Family"Planning $111.2"million $43.2"million Expanded"Primary"Health"Care N/A $100"million Breast/cervical"Cancer"Screening $17.9"million $24.5"million Total $201.4"million $240.1"million Source:*Texas*Health*and*Human*Services*Commission Prior"to"2012,"the"TWHP"was"administered"as"part"of"the"state s"medicaid"program"and"was"called"the" Women s"health"program"(whp)."in"2012,"the"federal"government"denied"the"state s"medicaid"waiver effectively"cutting"off"funding for"the"women s"health"program."as"a"medicaid"program,"the"women s" coverage"for"women s"health"services,"the"program"was"renamed"the"texas"women s"health"program," which"is"now"exclusively"funded"through"general"revenue."women"who"had"been"enrolled"under"the" Today,"the"TWHP"network"of"health"service"providers"is"comprised"of"3,853"certified"providers more" than"under"the"medicaid"program."the"twhp"also"offers"an"expanded"package"of"covered"services" compared"to"the"whp." City Number%of%TWHP% Providers%within%30%miles San"Angelo 39 Tyler 93 Abilene 19 McAllen 187 Amarillo 35 Source:*Texas*Women s*health*program 39 Presentation"to"Senate"Committee"on"Health"and"Human"Services:"Texas"Women s"health"and"family"planning"programs, " Texas*Health*and*Human*Services*Commission*&*Texas*Department*of*State*Health*Services,"Feb"20,"2014."" 40 10"

11 Texas"women provider"network"is"in"place"with"the"capacity"to"serve"more"than"170,000"women."the"texas"women s" million"in"the"previous"biennium.% The"84 th "Legislature"should"consider"increasing"funding"for"Texas"women s"health"programs"by"$50" million"and"direct"that"hhsc"use"the"increased"appropriation"to"expand"twhp up"screenings"for"women"with"abnormal"breast"or"cervical"cancer"test"results"or"cervical"dysplasia" treatment,"and"offer"individualized"case"management."hhsc"should"also"continue"to"actively"market"the" Texas"Women s"health"program"to"ensure"women"are"aware"that"they"may"be"eligible"to"enroll." Services%for%Survivors%of%Sexual%Assault%and%Abuse Recommendation:"Increase"appropriations"to"the"Office"of"the"Attorney"General"to"increase"by"100" provide"an"improved"level"of"care"and"compassion"for"victims,"along"with"careful"evidence"collection" and"the"expertise"needed"for"effective"prosecution." For"survivors"of"sexual"assault,"the"hours"immediately"following"the"attack"are"among"the"most" traumatic."a"sexual"assault"nurse"examiner,"or"sane"as"they"are"commonly"called,"is"a"registered"nurse" who"has"been"trained"to"(1)"provide"comprehensive"care"to"sexual"assault"patients;"(2)"conduct"a" medical"forensic"exam"and"evaluation"for"evidence"collection;"(3)"possess"the"expertise"required"to" provide"effective"courtroom"testimony;"and"(4)"display"compassion"and"sensitivity"to"sexual"assault" survivors. 41 "As"a"result"of"their"training,"SANEs"are"capable"of"providing"survivors"of"sexual"assault"with"a" superior"level"of"treatment"and"care"that"is"vital"to"victims "recoveries."sanes"also"ensure"evidence"is" collected"properly,"thereby"playing"a"critical"role"in"the"prosecution"of"sexual"assault"crimes." Even"if"a"victim"has"not"yet"decided"whether"to"report"an"incident"of"sexual"assault"to"law"enforcement," the"first"thing"all"survivors"should"do"is"obtain"a"medical"forensic"exam"for"the"purpose"of"evaluation"and" treatment"of"trauma"and"possible"infection,"counseling"referrals,"and"the"collection"of"evidence. 42 " Hospitals"are"often"the"starting"point"of"the"victim s"road"to"recovery,"as"well"as"their"initial"contact" point"with"the"criminal"justice"system."survivors"who"receive"proper"treatment"from"trained"sexual" assault"examiners"recover"from"the"physical"and"mental"trauma"of"an"assault"more"quickly"and"are"more" likely"to"follow"through"and"participate"in"the"prosecution"of"criminal"cases. 43 " 41 " Sexual"Assault"Nurse"Examiner"Program:"Frequently"Asked"Questions, "Office*of*the*Texas*Attorney*General,*March"31," 2011."" 42 "Id."" 43 "Id."" 11"

12 Dallas "first"sane"program"launched"in"2010,"and"within"four"months,"reporting"for"sexual"assaults"in" Dallas"County"rose"by"25"percent. 44 "As"hospitals"have"become"increasingly"aware"of"the"important"role" they"play"in"the"prosecution"of"sexual"assault"cases,"more"and"more"have"implemented"sexual"assault" Nurse"Examiner"programs"designed"to"provide"comprehensive"and"compassionate"care"to"survivors. 45 SANE"program"are"reported"to"run"between"$30,000"and"$40, "At"the"same"time,"SANE"nurses"can" conduct"a"forensic"medical"exam"more"efficiently"than"a"hospital"physician,"and"their"hourly"rates"are" much"lower,"leading"to"future"cost"savings"for"hospitals"that"train"and"employ"sane"nurses. 47 The"Office"of"the"Attorney"General"(OAG),"through"the"Sexual"Assault"Prevention"and"Crisis"Services,"a" program"of"the"crime"victim"services"division"that"certifies"sanes,"will"be"requesting"proposals"from" hospitals"for"participation"in"a"pilot"program"to"provide"funding"for"training"and"certification"of"sanes." The"program"will"endeavor"to"identify"qualified"instructors"to"train"SANE"nurse"candidates"in"evidence" collection"and"testifying"in"court."pilot"programs"such"as"this"one"are"useful"for"assessing"the"demand"for" SANE"training."Nationally,"SANE"training"per"person"costs"between"$250"for"basic"training"to"$1,200"for"a" week"of"advanced"clinical"training. 48 "Lawmakers"in"the"upcoming"session"should"examine"the"results"of" which"can"include"needs" assessments,"facilities"and"equipment,"staff"advertising"and"selection,"and"media"promotion as"well"as" training"and"certification"for"an"additional"100"sane"nurses"each"year."additionally,"lawmakers"should" work"with"the"state s"higher"education"nursing"programs"to"encourage"the"creation"of"more"sane" specialty"slots." 44 " Sexual"Assault"Nurse"Examiner"Program, "Texas*Health*Resources." 45 "Id." 46 " SANE"Development"and"Operation"Guide, "Office"for"Victims"of"Crime,"U.S."Department"of"Justice." 47 "Id." 48 *Id." 12"

13 Recommendation:"To"provide"more"services"and"greater"protection"for"victims"of"domestic"abuse," create"domestic"violence"high"risk"teams,"which"unite"law"enforcement,"medical"professionals"and" victim"advocates"at"the"local"level"to"review"cases"of"domestic"violence,"and"identify,"monitor,"and" contain"the"most"dangerous"perpetrators"before"they"can"inflict"deadly"harm. In"2012,"there"were"198,366"family"violence"incidents"in"Texas,"up"11.5"percent"from" "In"2012" alone,"domestic,"or"family"violence,"took"the"lives"of"114"women"in"texas,"12"more"fatalities"than" occurred"in" consequences. 51 "One"survey"found"that"women"who"identified"themselves"as"survivors"of"domestic" abuse"were"20"percent"more"likely"to"experience"a"chronic"health"condition"than"women"who"have" never"suffered"abuse. 52 "Survivors"of"abuse"also"reported"up"to"twice"as"many"chronic"health"conditions" compared"to"women"who"said"they"had"never"been"abused."it"follows"that"preventing"domestic"abuse" has"a"lasting"impact"on"a"woman s"health. Research"by"the"nation s"leading"expert"on"domestic"violence"suggests"that"the"single"biggest"indicator" for"domestic"homicide"is"a"prior"incidence"of"physical"domestic"violence. 53 "The"Jeanne"Geiger"Crisis" Center"(JGCC)"in"Newburyport,"Massachusetts"developed"the"Domestic"Violence"High"Risk"Team" Network,"an"innovative,"nationally"recognized"tool"for"preventing"domestic"violence"by"performing"risk" assessments"used"to"predict"when"a"violent"or"lethal"incident"is"likely"to"occur."the"assessments" evaluate"the"batterer s"history"and"behavioral"patterns,"allowing"law"enforcement"and"victim"services" providers"to"view"distinct"acts"of"violence"in"context."analyzing"lethality"factors"and"violent"behavior" 54 " 49 " Family"Violence, "Texas"Crime"Report"for"2012." 50 " Honoring"Texas"Victims:"Family"Violence"Fatalities"2012, content/uploads/2013/10/honoringtexasvictims_fullreport_8.5x11.pdf" 51 Domestic"Abuse"has"Long"Term"Health"Impact,"Survey"Says, "Liz"Neporent,"ABC*News,"Nov"5,"2013."" 52 "Id." 53 " A"Raised"Hand, "Rachel"Louise"Snyder,"The"New"Yorker,"July"22,"2013,"p."34." 54 " Working"to"Predict"and"Prevent"Domestic"Violence, "Suzanne"Dubus,"Champions"of"Change,"November"2,"2011." 13"

14 efforts"to"increase"victim"safety"by"monitoring"and"containing"perpetrators"while"providing"victim" services. 55 "Risk"assessments"allow"team"members"to"put"individual"incidents"of"violence"in"context"and" advocates,"probation"officials,"batterers "intervention"teams,"and"hospital"staff"in"order"to"create"a" s"first"eight"years,"92"percent"of"survivors"have"reported"that"there"have" 56 "The"DVHRT"model"has"been"replicated"in"21"communities"in"Massachusetts"and" several"others"across"the"country. 57 (Less"than"five"percent"of"cases"score"in"this"bracket;"for"those"that"do,"an"intervention"plan"is" immediately"put"into"place.)"and"experienced"zero"homicides." The"first"step"to"implementing"a"network"of"Domestic"Violence"High"Risk"Teams"in"Texas"is"the"creation" of"a"new"$2"million"annual"grant"program"under"the"purview"of"the"office"of"the"attorney"general. 58 " Implementing"a"DVHRT"model"in"Texas"can"be"achieved"using"existing"resources"of"the"various"agencies" and"entities"involved."additional"funding"for"the"new"program"could"come"from"federal"grants"solely" dedicated"for"the"prevention"of"family"violence."for"example,"in"the"2013"fiscal"year,"congress" appropriated"$409"million"for"violence"against"women"act"(vawa)"programs. 59 "Texas"is"eligible"for"a" were"used"to" develop"and"strengthen"effective"criminal"justice"strategies"and"victim"services"programs" to"combat"violent"crimes"against"women. 60 "Federal"law"requires"that"certain"amounts"of"these"grants" be"used"directly"for"prosecution,"law"enforcement,"victim"services,"and"court"costs,"but" the"remainder" of"the"funds"may"be"spent"at"the"discretion"of"the"state "to"provide"personnel,"training,"technical" assistance,"data"collection,"and"equipment"for"apprehension,"prosecution,"and"adjudication"of"persons" committing"violent"crimes"against"women. 61 "Grant"resources"would"be"awarded"to"law"enforcement" domestic"violence"in"their"respective"communities." 55 "Domestic"Violence"High"Risk"Team"Network,"Jeanne"Geiger"Crisis"Center." 56 " 57 " Making"An"Impact"By"Preventing"Domestic"Violence"Homicide, "Domestic"Violence"High"Risk"Team"Network,"Jeanne"Geiger" Crisis"Center." 58 "The"Jeanne"Geiger"Crisis"Center s"weekly"operating"budget"is"$38,000"($1,976,000"annually)."" 59 " Cardin,"Mikulski"Announce"$1"Million"Grant"To"Protect"High"Risk"Victims"of"Domestic"Violence, "March"28,"2013." "Legislative"Budget"Board," Top"100"Federal"Funding"Sources"in"the"Texas"State"Budget, "February"2013." 14"

15 Mental%and%Behavioral%Health%Care Recommendation:"Extend"loan"forgiveness"programs"to"mental"health"professionals"who"practice"in" underserved"areas. It"is"estimated"that"20"percent"of"Texas"adults"are"living"with"a"mental"illness,"and"four"percent"are" considered"serious"conditions. 62 "Approximately"300,000"children"in"the"state"are"suffering"with"a"serious" mental"health"condition. 63 "Rural"areas"are"particularly"underserved. There"are"some"incentives"in"place"to"entice"doctors"to"work"in"underserved"areas."The"National"Health" Service"Corps"(NHSC)" provides"financial"incentives"to"students"and"clinicians"in"exchange"for"practicing" at"approved"nhsc"sites"located"in"health"professional"shortage"areas"(hpsas). 64 "This"includes"licensed" primary"care"medical,"dental,"mental,"and"behavioral"health"providers. 65 "Texas"incentivizes"certain" practitioners"in"underserved"areas"by"providing"loan"forgiveness"of"up"to"$160,000"over"four"years" through"the"physician"education"loan"repayment"program"(pelrp). 66 "The"program"is"open"to"doctors"of" family"medicine,"internal"medicine,"pediatrics,"ob/gyn,"geriatrics,"and"psychiatry. 67 "Recipients"of"PELRP" must"work"in"designated"underserved"areas,"must"accept"medicaid"(and"chip"if"the"practice"includes" children),"and"cannot"refuse"a"patient"for"their"inability"to"pay. 68 "The"Texas"Medical"Association"calls"the" PELRP" a"critical"recruitment"tool, "and" one"of"the"most"successful"models"to"address"the"state's" physician"shortage " Scope"of"the"Problem, "Texas"Hospital"Association." 63 "Id." 64 " Texas"Primary"Care"Office"Information, "Texas*Department*of*State*Health*Services,*Aug"20,"2013.* 65 "The"NHSC"Loan"Repayment"Program,"National"Health"Services"Corps." 66 "Physician"Education"Loan"Repayment"Program,"Texas"Higher"Education"Coordinating"Board." 67 "Id." 68 " The"Physician"Education"Loan"Repayment"Program, "Legislative"Budget"Board"Issue"Brief,"Apr"2013." 69 " Physician"Loan"Repayment"Program:"A"Critical"Recruitment"Tool, "Texas"Medical"Association." 15"

16 Texas"has"375"federally"recognized"HPSAs,"the" second"highest"in"the"nation,"with"71.06"percent" of"the"need"met. 70 one 71 "and"are"lacking"practitioners"geographically" and"in"certain"population"groups,"and"also"lack" facilities. 72 "The"shortage"of"mental"health"services," however,"is"more"dire."texas"has"333"hpsa" designations"for"mental"health"(called"mhpsas)," and"only"46.75"percent"of"the"need"is"met. 73 "To" remove"that"designation,"the"state"will"require"at" least"193"practitioners"in"these"areas. 74 "(See" graphic) 75 The"state"should"revise"and"extend"the"Physician"Education"Loan"Repayment"Program"to"mental"health" professionals"who"provide"direct"care"services"as"employees"of"mental"health"authorities,"public" hospitals,"and"clinics"in"underserved"areas,"and"not"simply"limit"the"program"to"psychiatrists."this"could" include"licensed"professional"counselors,"licensed"clinical"social"workers,"and"licensed"psychologists." Eligibility"requirements"similar"to"the"requirements"for"PELRP"would"apply,"with"some"adjustments" regarding"licensing,"degrees,"and"time"served: Hold"the"appropriate"license"from"the"state"(Texas"State"Board"of"Examiners"of"Professional" Counselors,"Texas"State"Board"of"Social"Worker"Examiners,"Texas"State"Board"of"Examiners"of" Psychologists);" Hold"a"degree"from"an"accredited"Texas"institution"of"postsecondary"higher"education,"public"or" private; Be"eligible"to"take"the"exam"for"board"certification"from"specialty"boards"established"in"the" Texas"Higher"Education"Coordinating"Board"administrative"rules"if"the"individual"has"not"earned" and"maintained"board"certification; Agree"to"provide"five"consecutive"years"of"service"in"a"(1)"federally"designated"Health" Professional"Shortage"Area,"(2)"secure"correctional"facility"operated"by"or"under"contract"with" the"texas"juvenile"justice"department,"or"(3)"secure"correctional"facility"operated"by"or"under" contract"with"the"texas"department"of"criminal"justice; "Underserved"Areas"of"Texas,"Texas"Medical"Association. 72 "Mental"Health"HPSA"Designation"Overview,"Health"Resources"and"Services"Administration." 73 "Kaiser"Family"Foundation,"supra." 74 "Id." 75 " 2013"Mental"Health"Workforce"Shortage"Report"(August"Draft), "DSHSHealth"Professions"Resource"Center,"Sept"2014." 16"

17 Provide"direct"patient"care"to"Medicaid"enrollees"and"CHIP"enrollees"if"the"practice"includes" children; Not"be"currently"fulfilling"another"obligation"to"provide"medical"services"as"part"of"a"scholarship" agreement,"a"student"loan"agreement,"or"another"student"loan"repayment"program. 76 Licensed"professional"counselors"are"mental"health"professionals"with"master s"degrees"who"are" licensed"by"the"state. 77 "Professional"counseling"is"defined"as" the"application"of"mental"health," psychotherapeutic,"and"human"development"principles"to"facilitate"human"development"and" adjustment "along"with"prevention,"assessment,"and"evaluation. 78 "Licensed"clinical"social"workers"must" have"obtained"a"master s"degree"with"a"council"of"social"work"education"accreditation"or"a"doctorate"in" a"social"work"program 79 "and"are"authorized" in"the"areas"of"assessment,"diagnosis,"and"treatment"of" mental,"emotional,"and"behavioral"disorders,"conditions"and"addictions,"including"severe"mental"illness" in"adults"and"serious"emotional"disturbances"in"children. 80 level"degree 81 "and" diagnose"and"treat"mental,"nervous,"emotional,"and"behavioral"disorders"and" ailments. 82 " The"state"should"provide"additional"spots"for"PELRP"recipients,"reserved"for"these"mental"healthcare" professionals."as"a"starting"point,"an"additional"20"spots"would"cost,"at"the"most,"approximately"$1.2" million"for"the"first"biennium."as"the"pelrp"receives"the"majority"of"its"funding"from"the"smokeless" tobacco"tax, 83 "the"additional"costs"could"be"funded"the"same"way. Recommendation:"Offer"designated"mental"and"behavioral"health"screening"days"for"veterans"and" service"members"near"military"installations. The"services"in"this"recommendation"are"available"to"the"approximately"1.6"million"veterans, 84 "131,584" active"duty"military,"and"56,367"reserve"soldiers"and"national"guard"members 85 "who"reside"in"texas. 76 " PELRP"Fact"Sheet"Feb."2014, "HH"Loans,"Texas"Higher"Education"Coordination"Board." 77 " Who"Are"Licensed"Professional"Counselors, "American"Counseling"Association,"2011." " "DSHS"Center"for"Health"Statistics,"Health"Professionals" 81 " What"are"the"qualifications"to"become"licensed"as"a"psychologist"in"the"U.S.? "American"Psychological"Association." 82 "DSHS"Center"for"Health"Statistics,"Health"Professionals"Resource"Center,"supra." 83 "Legislative"Budget"Board,"Apr"2013,"supra." 84 " Veteran"Population, "Veterans"Administration." 85 " Military"and"Civilian"Personnel"in"Installations:"2009, "Census.gov." 17"

18 Iraq"and"Afghanistan,"ten"percent"of"Gulf"War"veterans,"and"30"percent"of"Vietnam"veterans"suffer"from" PTSD. 86 "Only"half"of"service"members"returning"from"the"wars"in"Iraq"and"Afghanistan"have"sought" treatment. 87 "For"those"who"do"seek"help"for"PTSD"or"major"depression,"only"half"receive"what" researchers"call" minimally"adequate "treatment. 88 "According"to"the"Armed"Forces"Health"Surveillance" Center," [m]ental"disorders"are"the"leading"cause"of"hospital"bed"days"and"the"second"leading"cause"of" medical"encounters"for"active"component"service"members"in"the"u.s."military, "and"that"number" increased"by"87"percent"from"2000"to" " Suicide"risk"is"a"particular"concern"for"veterans."Though"veterans"comprise"only"10"percent"of"the" population,"they"account"for"20"percent"of"suicides. 90 "Fortunately,"utilizing"proven"methods"of"treating" mental"health"issues"means"lessening"suicide"risk;"a"study"conducted"by"the"millennium"cohort"study" found"that"mental"health"and"substance"abuse"issues"were"significantly"related"to"suicide"risk,"while" combat"or"deployment"experience"was"not. 91 Problematically,"many"service"members"fear"they"will"be"penalized"or"their"careers"will"be"stalled"if"they" seek"mental"health"treatment"through"their"post"or"base."one"navy"commander"notes," [m]any"service" members"fear"that"seeing"a"psychologist"will"sink"their"careers "They"worry often"needlessly that" their"problems"will"get"back"to"their"bosses,"endanger"their"security"clearances"and"even"result"in"their" separation"from"the"service. 92 "The"military"has"put"forth"several"major"efforts"over"many"years"in" attempting"to"remove"the"stigma"and"treat"trauma. 93 Even"if"a"veteran"or"service"member"wants"to"seek"treatment,"the"backlog"at"their"local"Veterans" Administration"(VA)"may"prevent"timely"care."The"VA"has,"for"many"years,"been"criticized"for"a"lengthy" backlog"in"cases."in"march"2013,"the"va"waitlist"reached"600,000,"with"900,000"total"claims"pending " One"In"Five"Iraq"and"Afghanistan"Veterans"Suffer"from"PTSD"or"Major"Depression, "RAND,"Apr"17,"2008." 88 "Id." 89 " Medical"Surveillance"Monthly"Report, "Armed"Forces"Health"Surveillance"Center,"July"2013." 90 " Veterans'"access"to"mental"health"services"needs"fixing, "Ret."Lt."Col."Steve"Brozak,"CNN*Money,*Nov"11,"2013." 91 " Suicide,"Mental"Disorders,"and"the"US"Military:"Time"to"Focus"on"Mental"Health"Service"Delivery, "Charles"C."Engel,"MD," MPH,"The*Journal*of*the*American*Medical*Association,*Aug"7,"2013."" 92 " The"military s"war"on"stigma, "Sadie"F."Dingfelder,"Monitor*on*Psychology,*June"2009." 93 " Military"Looks"to"Redefine"PTSD,"Without"Stigma, "Larry"Abramson,"NPR,"May"14,"2012." 94 " The"Battle"to"End"the"VA"Backlog, 18"

19 The"VA"was"recently"caught"in"a"scandal"when"it"was"revealed"that"many"VA"clinics"were"falsifying" paperwork"related"to"wait"times"for"veterans"requesting"an"appointment,"so"as"to"make"it"appear"that" there"was"little"backlog. 95 "This"scandal"included"the"Austin"Outpatient"Clinic. 96 "Though"Congress"took" action"to"correct"the"issue,"the"va"is"still"making"errors"in"addressing"the"backlog. 97 "In"a"survey" conducted"by"iraq"and"afghanistan"veterans"of"america"of"their"members,"80"percent"of"respondents" felt"that"the"department"of"defense"and"va"were"not"providing"adequate"support"for"mental"health" injuries"and"issues. 98 "Only"29"percent"of"veterans"who"received"care"from"the"VA"also"received"mental" healthcare. 99 Veterans%who%Received%Mental%Health%Care%from%the%VA%Veterans%Health%Administration,%2006C2010 Source:*NAMI 100 So"that"veterans"and"service"members"can"receive"a"diagnosis"and"move"forward"with"treatment,"the" state"should"partner"with"qualified"providers"who"are"established"nearest"to"the"major"military" installations"in"texas Fort"Hood,"Fort"Bliss,"and"those"in"San"Antonio to"provide"designated"mental" health"screening"days"for"veterans"and"service"members"after"completion"of"a"screening,"the"individuals" can"take"the"next"necessary"steps"to"seek"treatment"based"on"their"referral." 95 " How"the"VA"developed"its"culture"of"coverups, "David"A."Farenthold,"The*Washington*Post,"May"30,"2014." 96 "Id." 97 " VA"is"making"disability"payment"errors"in"rush"to"cut"backlog,"watchdog"says, "FoxNews.com,"Jul"15,"2014." 98 "IAVA"Member"Survey"2013." 99 " Number"of"Veterans"Receiving"Care,"Barriers"Faced,"and"Efforts"to"Increase"Access, "Report"to"the"Ranking"Member," Committee"on"Veterans "Affairs,"House"of"Representatives,"United"States"Government"Accountability"Office,"Oct"2011." " New"Mental"Health"Coverage"for"Veterans, "National"Alliance"on"Mental"Illness"(NAMI),"Mar"2013." 19"

20 person"screening"events. 101 "State"health"agencies"also"coordinate"programs"with"the"military,"for" instance,"operation"lone"star,"a"partnership"between"dshs,"the"texas"military"forces,"and"local"health" departments,"coordinates"vaccinations"and"free"medical"care"for"texans"along"the"border. 102 Disability%Services The"notion"of"institutionalization"has"fallen"out"of"favor"as"a"method"of"treatment,"and"the"demand"for" State"Supported"Living"Centers"(SSLCs)"and"other"institutions"has"declined. 103 "The"1999"Supreme"Court" case"olmstead*v.*l.c.*required"states"to" eliminate"unnecessary"segregation"of"persons"with"disabilities" and"to"ensure"that"persons"with"disabilities"receive"services"in"the"most"integrated"setting"appropriate" to"their"needs The"state"should"work"to"ensure"that"people"with"disabilities,"their"families,"and"their"caregivers"receive" Department"of"Aging"and"Disability"Services"waitlist"for"community"care"is"in"fact"called"an"interest"list"as" there"is"a"strong"demand"for"these"services." need"to"live"at"home"independently."a"person"with"a"disability"may"have"a"higher"quality"of"life"with"this" option,"and"many"prefer"it"to"institutional"living"as"they"can"choose"the"attendant"who"best"fits"their" lifestyle. There"are"several"Department"of"Aging"and"Disability"Services"(DADS)"programs"that"provide"home"care" or"community"services"for"those"with"physical"or"intellectual"disabilities."many"are"waitlisted: " Operation"Lone"Star"Brings"Free"Medical"Care"to"South"Texas, "DSHS"News"Release,"Jul"19,"2011." " Transform"State"Residential"Services"for"Persons"with"Intellectual"and"Developmental"Disabilities, "Legislative"Budget"Board" Staff,"Jan"2011." 104 " Olmstead:"Community"Integration"for"Everyone, "ADA." 20"

21 DADS%June%2014%Interest%List%Summary% 105 Program Number"Enrolled" Number"Still"on" Interest"List Longest"Wait"Time" on"interest"list Community"Based"Alternatives" (CBA) Community"Living"Assistance" and"support"services"(class) 1,387 7,072 1"year 88 51,080 Services"Program"(HCS) , represent"significant"cost"savings"according"to"the"national"council"on"disability."in"2009,"the"average" 107 " Despite"their"necessity,"the"turnover"rate"for"qualified"personal"attendants"is"high,"as"the"work"is" demanding"and"the"pay"is"low."currently,"the"wage"set"for"personal"attendants"varies"but"is"usually" $7.50"per"hour $0.25"more"than"the"federal"minimum."In"FY"2013,"the"five"HHS"agencies 108 "had"a" turnover"rate"of"22.9"percent,"totaling"13,000"employees,"compared"to"17.6"percent"statewide. 109 " General"Revenue"($16.6"million"All"Funds)"to"support"a"five"percent"wage"increase"for"DADS"direct"care" support"professionals. 110 "HHSC"has"also"requested"$97.9"million"in"General"Revenue"($223.5"million"All" Funds)"to"increase"community"attendant"care"professionals "wages"by"five"percent. 111 "The"state"should" support"this"increase"in"order"to"recruit"personal"attendants"so"consumers"may"have"a"choice"in"their" care"and"retain"workers"that"meet"their"needs"with"whom"they"feel"comfortable." " Forging"Ahead:"Developing"a"Plan"and"Building"Community"Capacity, "National"Council"on"Disability." "The"five"agencies"that"comprise"the"HHS"system"are:"Health"and"Human"Services"Commission,"Department"of"Aging"and" Disabilities"Services,"Department"of"State"Health"Services,"Department"of"Assistive"and"Rehabilitative"Services,"and"Department" of"family"and"protective"services" 109 "HHSC"Exceptional"Item"Request,"Legislative"Appropriations"Request"(84R)"Version"1,"Aug"18,"2014."" 110 "Id." 111 "Id." 21"

22 Increasing%Accountability%of%Benefits Recommendation:"Transform"social"service"delivery"and"provide"more"comprehensive"support"by" According"to"a"2012"study," 2008 third"in"the"nation,"behind"california"and"new"york. 112 "At"the"same"time,"tens"of"thousands"of" Texans"receive"public"benefits"every"year.""For"example,"112,431"Texans"received"TANF"benefits"in" December" "The"burden"on"taxpayer"resources"represented"by"public"assistance"programs"can"be" reduced"by"enabling"charitable"organizations"to"directly"contact"to"families"in"need." 114 "Public" assistance"programs,"such"as"tanf,"ultimately"amount"to"little"more"than"a"financial"transaction."by" allowing"charitable"groups"to"participate,"tanf"and"similar"programs"are"infused"with"a"personal" element,"affording"recipients"the"opportunity"to"receive"assistance"that"adopts"a"comprehensive" approach."charitable"organizations"focus"on"improving"lives"by"helping"individuals"overcome"barriers"to" opportunity"to"realize"their"true"potential,"which"ultimately"may"yield"better"results"by"allowing"more" people"to"become"independent." " existing"benefits,"which"they"would"continue"to"receive"for"as"long"as"they"remain"eligible"and"enrolled." Texans"who"wish"to"be"contacted"will"have"their"information"released."This"mechanism"will"enable" charitable"organizations"to"reach"out"directly"to"persons"in"need"and"maximize"the"effectiveness"of" charitable"benefits. Recommendation:"Request"federal"Medicaid"funds"in"the"form"of"a"block"grant. Because"Medicaid"is"an"entitlement"program"and"must"serve"everyone"who"qualifies"and"enrolls,"its" weakness"is"that"it"is"difficult"to"cover"very"different"populations"with"very"different"needs. 115 "Medicaid" is"in"dire"need"of"reform"by"giving"the"states"more"local"control"in"the"form"of"block"grants. 112 ""How"States"Stack"Up"in"Generosity, "Tex."Health"and"Human"Services"Code" " 115 " It s"time"to"remake"medicaid, "Stuart"M."Butler,"Ph.D.,"The*Heritage*Foundation,"June"6,"2012." 22"

23 Block"grants"for"Medicaid"have"been"pushed"for"decades,"first"by"President"Ronald"Reagan"in"1981,"then" by"house"speaker"newt"gingrich"in"1995,"and"by"president"george"w."bush"in" "Some"efforts" have"been"successful."there"are"recent"examples"of"the"federal"government"giving"effective"block"grants" of"medicaid"funds"to"states,"and"these"generally"have"led"to"greater"policy"innovation"and"the"saving"of" taxpayer"money."for"example,"in"indiana,"a"waiver"allowed"the"state"to"introduce"subsidized"health" Savings"Accounts"(HSAs)"into"its"Medicaid"program a"popular"reform"that"surveys"at"a"94"percent" satisfaction"rate. 117 "(Problematically,"the"Obama"Administration"denied"a"request"to"extend"this"waiver" when"it"expired"in"2012). 118 "Similarly,"a"block"grant"the"George"W."Bush"Administration"approved"for" Rhode"Island"saw"major"success: Rhode"Island"was"able"to"save"$100"million,"and"slow"the"growth"of"Medicaid"from"8"percent"per" year"to"3"percent,"by"making"a"few"tweaks"to"their"program"that"they"couldn t"before:"shifting" management"programs;"etc. 119 Medicaid"spending"already"comprises"more"than"one"quarter"of"the"state"budget. 120 "Federal" Medicaid"rules"are"overly"restrictive"and"make"it"difficult"to"implement"innovative"plans"to" reduce"costs."the"texas"medicaid"provider"procedures"manual"(updated"monthly)"is"currently" over"1,800"pages"long."doctors"are"not"only"leaving"the"program"for"reimbursement"reasons," but"also"because"compliance"is"difficult"and"convoluted. 121 " 116 " How"Medicaid"Block"Grants"Would"Work, "Mary"Agnes"Carey"and"Marilyn"Werber"Serafini,"Kaiser*Health*News,"Mar"6," 117 " "Avik"Roy,"Forbes,"September"30,"2013." 118 " Obama"Administration"Denies"Waiver"for"Indiana's"Popular"Medicaid"Program, "Avik"Roy,"Forbes,"November"11,"2013." 119 "Roy,"September"30,"2013,"supra." 120 " "Legislative*Budget*Board,"Feb"2014." 121 "Texas"Medicaid"Provider"Procedures"Manual"Volumes"1"and"2,"July"2014." 23"

24 Even"the"waiver"process,"which"allows"states"to"exempt"themselves"from"certain"Medicaid" provisions"and/or"receive"authorization"to"implement"innovative"delivery"models"for" healthcare"services,"takes"years"to"complete"and"implement."for"instance,"in"2011"texas" pool"that"would"allow"regional"healthcare"providers"to"utilize"billions"of"dollars"in"funding"over" five"years"for"experimental"projects"aimed"at"improving"health"outcomes. 122 ""Federal"approval" for"more"than"1,100"projects"under"the"waiver"was"not"secured"until"may"2013,"and" approximately"200"additional"projects"were"not"approved"until"summer"of" "Many"of" the"approved"projects"required"two"years"to"implement."the"time"and"resources"exhausted"in" state"was"allowed"to"operate"its"medicaid"program"without"the"constant"need"for"approval" from"the"federal"centers"for"medicare"and"medicaid"services." Recent"experience"with"block"grants"demonstrates"clearly"that"states"can"pioneer"new"and" effective"policies"and"use"funds"more"efficiently"if"they"have"more"discretion"over"how"to"use" Medicaid"funding,"which"would"be"accomplished"by"the"state"receiving"these"funds"as"a"block" grant."texas"should"request"the"federal"government"provide"medicaid"funds"in"the"form"of"a" block"grant. State%ConsumerCDirected%Health%Plan% Recommendation:"Allow"eligible"participants"of"the"group"benefits"program"under"the"Texas" Employees"Group"Benefits"Act"to"enroll"in"health"savings"accounts"(HSAs)." Currently,"the"group"benefits"program"(GBP)"under"the"Texas"Employees"Group"Benefits"Act"provides" (ERS)"for"state"employees,"retirees,"and"their"dependents. would"allow"the"state"to"make"a"contribution"for"those"who"select"the"cdhp"equal"to"the"contribution" contribution"for"healthcare"expenses"into"their"hsa." 122 "HHSC"Texas"Healthcare"Transformation"and"Quality"Improvement"Program"Medicaid"1115"Waiver"Proposal,"July"13,"2011." 123 "HHSC"Presentation"to"the"House"County"Affairs"Committee"on"the"Healthcare"Transformation"Waiver,"May"15,"2014." 24"

25 Currently,"state"employees"may"participate"in"the"TexFlex"program"by"enrolling"in"a"TexFlex"account,"a" 124 "Starting"in"2015,"TexFlex"will"allow"members"to"roll"up" to"$500"of"unused"funds"over"to"the"subsequent"year;"however,"all"funds"in"excess"of"$500"remaining"in" the"account"at"the"end"of"the"year"will"be"forfeited. 125 "HSAs"present"several"advantages"over"FSAs,"not" the"least"of"which"is"the"fact"that"hsa"funds"may"be"carried"forward"from"year"to"year. 126 " 2010"New*York*Times"article"quoted"an"industry"trade"group"to"the"effect"that"the"number"of"people" enrolled"in"hsas"stood"at"more"than"10"million,"up"from"6.1"million"in" HSAs"require"a"person"to"be"covered"by"a"HDHP,"which"under"federal"law"must"have"at"least"a"$1,200" network"services"may"not"exceed"$5,950"($11,900"if"the"plan"is"family"coverage). 128 "These"amounts"are" adjusted"annually"to"account"for"inflation."the"disadvantage"of"the"high"deductible"is"balanced"by"the"tax" advantages"of"an"hsa"and"the"lower"premiums"the"hdhp"charges." Once"a"person"is"covered"by"an"HDHP,"he"or"she"may"contribute"to"an"HSA."The"amount"contributed"is" 129 earnings"(e.g.,"the"interest"on"the"balance"in"the"hsa)."the"cap"on"contributions"to"hsas"for"2011"is" A"consumer"can"put"money"in"the"account"up"to"the"maximum"federally"mandated"limit,"and"that" money"stays"there"until"it"is"used"for"a"qualified"medical"expenditure."(the"money"may"be"withdrawn"for" any"purpose,"but"withdrawals"that"are"not"for"qualified"medical"expenses"are"assessed"a"10"percent"tax" penalty.)" 124 "ERS"TexFlex"Health"Care." 125 "ERS"FAQ"TexFlex." 126 " Health"savings"vs."flexible"spending"accounts, "Hadley"Malcolm,"USA*Today,"Oct"7,"2013." accounts/ /" 127 " High"Deductible"Plans"Grow,"But"Not"Everyone"Should"Get"on"Board, Walecia"Konrad,"New*York*Times,*August"27,"2010," available"at" Obamacare )"increases"the"penalty"for"withdrawing"hsa"funds"for" qualified"medical"expenses. "Certain"provisions"of"the"PPACA"may"affect"HSAs"in"the"future,"but"specifics"are"not"available" because"too"much"is"contingent"on"regulations"yet"to"be"issued."" 25"

26 By"allowing"some"employees"to"opt"for"HSAs"the"state"can"expect"to"generate"cost"savings"compared"to" the"traditional"public"employee"health"benefit"plan"provided"by"a"health"maintenance"organization" cost"of"public"employee"healthcare"plans"was"increasing"by"7.6"percent"per"year"for"hmo"health" insurance"premiums."by"contrast,"the"mackinac"center"noted"that"state"costs"for"an"hsa"employee" benefit"package"would"grow,"conservatively,"at"an"annual"rate"of"just"3.5"percent. 130 The"Mackinac"Center"also"points"out"that"contributing"the"maximum"amount"to"employees "HSAs"would" be"a"significant"benefit"for"state"employees: This"would"be"a"huge"benefit"to"state"employees"as"very"few"employers"provide"health"savings" account" users" 100" percent" premium" support" " much" less" full" funding" for" HSAs." In" fact," according"to"a"survey"of"6,000"employers"by"information"strategies"inc.,"fewer"than"10"percent" of"respondents"contribute"100"percent"of"the"allowed"contributions. 131 At"the"state"level,"Indiana"has"had"significant"success"implementing"HSAs"for"state"employees."Seventy" percent"of"indiana s"state"employees"are"enrolled"in"hdhps"coupled"with"hsas,"which"are"offered"as" employees"have"a"total"of"$30"million"in"their"accounts"($2,000"per"employee)"and"their"healthcare"costs" Most" important," we" are" seeing" significant" changes" in" behavior," and" consequently" lower" total" costs."in"2009,"for"example,"state"workers"with"the"hsa"visited"emergency"rooms"and"physicians" use"generic"drugs"than"those"enrolled"in"the"conventional"plan,"resulting"in"an"average"lower" cost"per"prescription"of"$18."they"were"admitted"to"hospitals"less"than"half"as"frequently"as"their" colleagues..."overall,"participants"in"our"new"plan"ran"up"only"$65"in"cost"for"every"$100"incurred" by"their"associates"under"the"old"coverage. 132 " The"private"sector"also"demonstrated"the"significant"fiscal"benefits"of"HSAs."In"April"2008,"America s" Health"Insurance"Plans"reported"that"6.1"million"people"are"now"covered"by"HSAs,"a"significant"increase" over"the"4.5"million"who"were"covered"by"hsas"a"year"earlier"and"almost"double"the"3.2"million"account" holders"in" "According"to"a"survey"of"152"large"employers"conducted"by"Deloitte"Consulting,"40" the" most"effective"approach"for"managing"costs"and"maintaining"quality"care. 134 " 130 " State"Should"Adopt"Health"Savings"Accounts, "The"Mackinac"Center"for"Public"Policy,"September"28,"2007."" 131 "Ibid." 132 " Hoosiers"and"Health"Savings"Accounts, "Editorial"in"the"Wall*Street*Journal,*March"10,"2010." 133 "America s"health"insurance"plans,"center"for"policy"and"research,"april"2008." 134 " Reducing"Corporate"Health"Care"Costs"2006"Survey, "Deloitte"Consulting"LLP,"2006." 26"

27 This"proposal"should"have"no"fiscal"impact"on"the"state"or"the"GBP"because"the"HDHP"offered"to"state" employees"would"have"lower"premiums"than"the"traditional"benefits"package."the"difference"between" the"costs"of"the"two"plans"would"be"deposited"in"the"employee s"hsa."these"deposits"would"be"adjusted" to"ensure"cost"neutrality."as"the"legislative"budget"board"noted"of"a"similar"legislative"proposal"in"2013: The"bill"directs"the"state"to"contribute"the"excess"over"the"cost"of"the"high"deductible"plan,"if" any,"of"the"amount"that"would"otherwise"be"made"on"the"member's"behalf"under"healthselect" to"a"health"savings"account."ers"reports"that"these"amounts"would"be"adjusted"to"neutralize"the" cost. 135 Maintaining"cost"neutrality"is"therefore"a"critical"component"of"this"proposal. Telemedicine In"the"face"of"a"surging"population,"concerns"are"growing"over"a"physician"shortage"in"Texas,"particularly" in"the"area"of"primary"care. 136 "In"2010,"Texas"had"165"physicians"per"100,000"people,"compared"to"the" national"average"of"220"physicians. 137 "The"Department"of"State"Health"Services"reports"that"126"of"the" state s"254"counties"do"not"have"enough"primary"care"physicians. 138 "Meanwhile,"the"rising"cost"of" healthcare"is"exacerbating"problems"created"by"the"state s"physician"shortage. 139 "As"policymakers"search" for"opportunities"to"improve"access"to"care"and"contain"costs,"telemedicine"has"emerged"as"a"promising" Telemedicine"uses"technology"to"deliver"medical"care"to"patients"remotely."Texas"regulations"define" telemedicine"medical"service"as" [t]he"practice"of"medical"care"delivery,"initiated"by"a"distant"site" provider,"who"is"physically"located"at"a"site"other"than"the"site"where"the"patient"is"located,"for"the" purposes"of"evaluation,"diagnosis,"consultation,"or"treatment"which"requires"the"use"of"advanced" telecommunications"technology"that"allows"the"distant"site"provider"to"see"and"hear"the"patient"in"real" time. 140 "" " Despite"Additional"Dollars,"Texas"Doc"Shortage"Is"Hard"To"Fix, "Becca"Aaronson,"The*Texas*Tribune"and"Kaiser*Health*News," 137 "Id." 138 "Id." 139 " Health"Care"Costs"in"Texas, "The"Texas"Economy,"Texas"Comptroller"of"Public"Accounts." "22"TAC"174.2(10)" 27"

28 Telemedicine"offers"significant"access"to"care"benefits"to"employees,"rural"residents,"travelers,"and"the" culturally"isolated. 141 "With"telemedicine,"employees"are"not"required"to"take"time"off"work"in"order"to" consult"with"a"physician"and"can"receive"timely"treatment"and"care. 142 "Similarly,"rural"residents"and" needs."finally,"the"best"telemedicine"providers"are"able"to"offer"a"multilingual"helpline"24"hours"a"day"to" help"the"most"culturally"isolated"members"of"the"workforce"receive"care"in"a"manner"comfortable"to" them. 143 " In"light"of"growing"interest"in"telemedicine,"a"new"Federation"of"State"Medical"Boards"model"policy"aims" to"create"guidelines"for"its"safe"and"appropriate"practice."the"policy"parallels"existing"texas"medical" standard"of"care"remains"the"same. 144 " Currently,"Texas"law"authorizes"the"use"of"telemedicine"services."Supporting"the"expanded"use"of" technology"for"telemedicine"will"increase"access"to"affordable"healthcare,"particularly"for"texans"in"rural" areas."for"these"individuals,"checkups"and"treatment"for"important"health"issues"are"often"delayed"due" to"a"lack"of"access."telemedicine"encourages"preventive"care"through"expanded"access." To"protect"patients"who"seek"treatment"through"telemedicine"services,"TMB"Rules"require"that" physicians"who"use"telemedicine"in"their"practices"be"licensed"in"all"jurisdictions"where"their"patients" reside,"adopt"protocols"to"prevent"fraud"and"abuse,"discuss"the"risks"and"benefits"of"the"service"with"the" clinical"settings. 145 "Importantly,"TMB"Rules"also"differentiate"between"two"types"of"telemedicine:" medical"services"delivered"while"the"patient"is"present"at"an"established"medical"site,"and"medical" services"provided"at"sites"other"than"an"established"medical"site."patients"may"typically"only"receive" 146 "This"means"when"a"patient"complains"about"an"earache"through"a" must"occur"during"a"telemedical"visit"as"well." 141 "Tommy"G."Thompson,"et"al," "2013." 142 "Id." 143 "Id.*" 144 "Texas"Medical"Board"Rules" 174.8(b)" 145 "Texas"Medical"Board"Rules,"Chapter"174" 146 "Texas"Medical"Board"Rules" 174.7" 28"

29 Recommendation:"Encourage"pay"parity"for"phone"consultations"by"allowing"a"physician"to"charge"for" a"telephone"consultation"with"a"covered"patient"if"an"employee"benefit"plan"or"health"insurance"policy" allows"any"other"person"to"charge"for"telephone"consultations"with"covered"patients. effective"means"of"improving"healthcare"outcomes"in"the"state."phone"consultations"provide"patients" with"an"alternative"to"costly"urgent"care"and"emergency"room"visits,"and"give"physicians"the"flexibility"to" serve"more"established"patients"after"hours"virtually"anywhere"in"the"state." Some"insurers"contract"under"exclusive"relationships"with"vendors"that"provide"telephone"access"to" physicians"located"outside"the"state,"while"disallowing"payment"for"the"same"activity"among"community" physicians. 147 the"patient"to"whom"they"are"providing"services,"as"well"as"hospital"admitting"privileges"in"a"regional" hospital."such"physicians"typically"will"not"have"means"to"physically"treat"and"see"patients"in"the"follow" up"after"the"phone"consultation." By"prohibiting"insurance"companies"that"pay"physicians,"including"those"physicians"residing"outside"the" state"or"the"community,"for"telephone"consultation"services"within"the"terms"of"an"offered"health"plan" from"discriminating"against"local"physicians"offering"similar"services,"lawmakers"can"promote"continuity" of"care"and"decrease"the"number"of"expensive"emergency"room"visits."legislation"introduced"during"the" 83 rd "Legislative"Session"would"have"required"payment"parity"for"telephone"consultations."While"that" legislation"did"not"pass,"the"84 th "Legislature"should"examine"the"issue"of"how"best"to"address"the"issue"of" payment"parity"for"telephone"consultations. Supporting%the%Medical%Profession Recommendation:"Increase"the"number"of"residency"positions"available"in"Texas"for"medical"school" graduates. Texas"is"a"net"importer"of"physicians;"however,"due"to"continued"growth"of"the"state s"population,"the" ratio"of"physicians"to"100,000"population"has"remained"nearly"stagnant. 148 "In"2012,"the"national"average" of"physicians"per"100,000"population"was""46.1"primary"care"physicians"and"65.5"specialists. 149 "Texas" ranks"near"the"bottom"(43 rd "among"the"50"states)"for"physicians"per"100,000"population. 150 "" 147 " Digital"Doctor, 148 Graduate"Medical"Education"Report, "Texas"Higher"Education"Coordinating"Board"(THECB),"April"2012." ""Centers"for"Disease"Control"and" Prevention"(CDC)," 150 " Feeding"the"Physician"Pipeline:"TMA"forum"promotes"GME"expansion, "Medical"Education,"November"2013." 29"

30 In"2012,"Texas"ranked"49 th "in"the"nation"on"the"number"of"primary"care"physicians,"with"33.6"per" 100,000"population. 151 " Texas"increased"its"medical"school"enrollments"31"percent"from"fall"2002"to"fall"2012,"growing"from" 1,342"to"1, "In"2011,"Texas"had"550"residency"programs"offering"6,788"residency"positions. 153 " Coordinating"Board"(THECB)"estimates"that"approximately"137"graduates"of"the"2015"Texas"medical" 154 "To"meet"future"physician"demands," Texas"must"promote"opportunities"for"the"graduates"of"Texas "medical"schools"to"obtain"their"residency" training"within"the"state." During"the"83 rd "Legislative"Session,"the"Texas"Legislature"acted"to"address"this"problem"with"a"$30" 155 "The" Legislature"also"appropriated"$1,875,000"for"Planning"Grants"and"$7.375"million"for"Unfilled"Position" Grants"and"New"and"Expanded"Program"Grants."" not"previously"operated"a"gme"program"and"are"therefore"eligible"for"medicare"gme"funding.""these" $150,000"grants"are"intended"to"provide"support"for"establishing"GME"programs"in"order"to"increase"the" 156 "Nine"such"grants"were"announced"in"December" 2013,"and"THECB"plans"to"the"award"three"additional"grants"in"fall" CDC,"Supra"at"note"152" 152 " An"Update"on"Graduate"Medical"Education"in"Texas, "Texas"Higher"Education"Coordinating"Board"(THECB),"February"2013." 2EF7F570559D33F0&typename=dmFile&fieldname=filename" 153 THECB","Supra*at"note"155" 154 "THECB","Supra*at"note"155" 155 "See"Senate"Bill"1"and"House"Bills"1025"and"2550." 156 "House"Bill"1025"(83R)."" 157 " "Texas"Higher"Education"Coordinating"Board"(THECB)," August"2014." 30"

31 Unfilled"Position"Grants"and"New"and"Expanded"Program"Grants"are"jointly"funded,"with"a"maximum" allowable"award"of"$65,000"per"resident"per"year. 158 "The"Unfilled"Position"Grants"may"be"awarded"to" Expanded"Program"Grants"may"be"provided"to"entities"with"Accredited"GME"Programs"to"provide" 159 "The" grants"are"intended"to"pay"for"direct"resident"costs,"including"resident"stipends"and"benefits. 160 "50" Unfilled"Position"Grants,"totaling"$3.25"million"were"awarded"in"FY" "Approximately"$4.2"million"is" available"for"unfilled"position"grants"and"new"and"expanded"program"grants"in"fy"2015,"enough"to" cover"approximately"64"positions. 162 " Texas"lawmakers"should"continue"to"authorize"funding"in"sufficient"levels"to"support"the"Unfilled" 158 "Id." 159 "House"Bill"1025"(83R)" 160 "House"Bill"1025"(83R)" 161 THECB,"Supra*at"note"160" 162 THECB,"Supra*at"note"160" 31"